CONSULTATION / PROCEDURE REFERRAL FORM Fields marked (*) are required. Patient Name:* MRD No:* Sex:* Male Female DOB:* Tel No:* From (Referring Doctor):* Select a doctor Dr Abdul Razzak Juratli Dr Abduldayem Mando Dr Abdullah Davoodbhoy Dr Adel Abushi Dr Adel Ahmed El Naggar Dr Adel Eryani Dr Aditya Bhabhe Dr Ahmad Abdul Rahman Dr Ahmed Al Kamali Dr Ahmed ElMansoury Dr Ahmed Ibrahim Mostafa Dr Ahmed Mohammed Al Kamali Dr Amjed Alhilo Dr Amna Naveed Dr Anoop Kumar Joshi Dr Archana Nair Dr Arif Adenwala Dr Arun Kunhiraman Dr Ashar Jamal Dr Ayman Moustafa Hassan Dr Bahaa Al Nashi Dr Bassam Hasan Dr Bassam Mikaiel Toubal Dr Bassant Amer Dr Betty John Dr Bobby Jose Dr Brian Mtemererwa Dr Deepak Bhatia Dr Deepika Gandhi Dr Dena Mohamed Abdel Raof Dr Dena Samir Abdelhady Dr Dinesh Vaidya Dr Ehsan Ahmad Dr Emad Mohammed El Shafie Dr Fadil Al Azzawi Dr Faheem Tadros Dr Harith Hamdan Dr Hazem Daaji Dr Hazim K. Al Mance Dr Hermann Ulrich Honemeyer Dr Hossameldin Maged Dr Islam Badr Dr Israa Khalid Dr Kamal Hussein Saleh Dr Karim Antoine Attara Dr Kausar Perveen Dr Khalid Ali Khan Dr Kowshik Gupta Dr Lakshamana Rajan Dr Lilly Jose Dr Loai Eid Dr M Sona Rajan Dr Mah Sheena K Mohammed Dr Mais Ibrahim Dr Manal Saad Dr Manjiri Bapat Dr Manoj Singh Dr Manoja Widanagama Dr Milind Raje Dr Mohamad Abdulkader Karima Dr Mohamad Azzam Ziade Dr Mohamed Adel Abo Ghanima Dr Mohamed Fahmy Dr Mohamed Zedan Dr Mohammad Al Hasoun Dr Mohammad Aldisi Dr Mohammad Horan Dr Mohammed Istrabadi Dr Mohammed Riffat Alsharaky Dr Mona Zakariya Dr Mustafa Hassan Marai Dr N. Selvakumari Dr Nawal Ibraheem Dr Nawras Mohammad Al Hawa Dr Nidhi Panwar Dr Nisha Soares Dr Nishanth Sanalkumar Dr Pawan Nath Dr Prachet Kulkarni Krishnamurthy Dr Prem Tanwar Dr Rabab Mehdi Hilmy Dr Rafik Abu Samra Dr Ram Shukla Dr Reham Omar Dr Riadh Khudhier Dr Ricardo A. P. Persaud Dr Rim Kharis Dr Rupesh Singh Dr Saeid Taghizadeh Dr Saji Varghese Dr Salahudeen Fizal Dr Samar Ali Dr Sameh Ali Dr Samia Wadie Samy Dr Sanjiv Kumar Kakkar Dr Shahzada Zubair Dr Shama Nawaz Dr Shamail Suliman Shaheen Dr Sheela Prince Dr Shekhar V. Shikare Dr Sherief Elsayed Dr Shwan Hameed Dr Shyamsunder Nair Dr Sukrith Shetty Dr Sulfi Rahumathulla Dr Syed Rabbani Dr T. Sathish Kumar Dr Taimaa Shtayyan Dr Wedad Nabih Ahmed Dr Wissam Jamal Al Tamr Dr Yalda Zargham Ziaei Dr. Abeer Abdel Aaty Soliman Dr. Ashley Thomas Dr. Ateesh Borole Dr. Biju Pankappilly Dr. Dev Roy Dr. Dhaval Darji Dr. Edgar Edmond Irany Dr. Fadel Husrom Dr. Fadi Alnehlaoui Dr. Farha Dheeba Khan Dr. Fekry ElDeeb Dr. Hala Khalifa Dr. Hala Maher Dr. Hiba Alla Maskji Dr. Jabir R Hameed Dr. Jayasheela Kannan Dr. Mohamed Abou Koutah Dr. Mohamed Nada Dr. Mohammed Mustafa El Mahy Dr. Mohammed Sala Uddin Dr. Mohammed Shabbir Dr. Mona Omar Suleiman Dr. Nancy Nabil Dr. Nile Abo Baker Dr. Nusaiba Ghanem Dr. Pooja Agrawal Dr. Pramod Subash Dr. Rajan Maruthanayagam Dr. Rajeev Kamble Dr. Renuka Joshi Dr. Rohit Raja Dr. Roleen Pereira Dr. S Julide Sagiroglu Dr. Saji Sreedharan Pillai Dr. Shalini Shanmugam Dr. Sirar Al Ali Dr. Suvadip Chatterjee Dr. Syed Adnan Dr. Tamer Orief Dr. Tamer Saafan Dr. Tharwat Saleha Dr. Venkatesh Manchikanti Dr. Walid Shaker Dr. Yasser Menaissy Dr. Zulqarnain Kazim Anjum Mr. Mirshad Vattiyam Veettil Mr. Rhandy M Navarro Mr. Vimal Kurian Ms Khatheeja Basheer Ms. Ani Varghese Ms. Divya Prabhu Ms. Dona Dolly Thomas Ms. Jinjumol P Mathew Ms. Meethu Thomas Ms. Sophia Jogi Ms. Zainab Qayyum Referred To:* Referred Date and Time:* Type of referral:* Internal Referral External Referral Procedure Referral Category:* Urgent Routine Referral As:* OPD In-Patient ICU Type of Consultation:* Consultation Only Consultation with Directive Care Consultation with Continuing Care Transfer PART A (To be filled by Most Responsible Physician) Reason for referral and clinical details: Kindly examine and advise. Thank you.Stamp and signature of the Most Responsible Physician. Signature Date and time * DEFINITIONS Consultation only: Consultant is asked to make an assessment and management suggestions. Consultation with directive care: The consultant assists with the ongoing care of the patient including appropriate orders and follow up. The consultant is not the most responsible physician. Consultation with continuing care: Consultant takes over the entire care of the patient and becomes the Most Responsible Physician
